Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide a resident or the resident's legal representative with a copy of the resident's medical record upon request and within the required timeframe, as outlined in the facility's own policy and procedure. The resident, who was admitted with lumbar region stenosis and hypertension and required substantial assistance with activities of daily living, had intact cognitive skills according to the Minimum Data Set. A signed HIPAA-compliant authorization for the release of patient information was present, and a formal request for records was made to the medical records assistant. Despite these requests, the legal assistant reported that the facility continued to send incomplete printed and scanned records instead of the requested electronic format from the Point Click Care system. The facility's policy required electronic access or copies to be provided within 24 to 48 hours, excluding weekends and holidays, when records are maintained electronically. The Director of Medical Records acknowledged that the department did not follow the established policy and procedure, resulting in the resident's representative not receiving the medical records in a timely manner.